Program Request Form

On The Road Program Request Form"08"-"09" Please return to jgoehrke@rockhall.org or fax to 216-515-1931 Thank you for your interest in the Rock and Roll Hall of Fame and Museum Distance Learning Programs. Please submit one form for each program and/or teacher request via fax or email. Registrations must be received at least 3 weeks prior to the requested date and are booked on a first come, first served basis. Organizations must agree to abide by the terms and conditions outlined in "Policy Information" in order to have their registration request processed. If you have any questions regarding scheduling, please contact John Goehrke at 216-515-1202.

STUDENT PROGRAMS (All programs cost $100.00)	Ambassador to the Orchestra: The Arranger in Rock and Roll	Ball of Confusion: Rock Music and Social Change in the 60's and 70's	Ball of Confusion II: Rock Music and Social Change in the 80's and Beyond
	Great Moments in Rock and Roll: Popular Music Through the Decades	Grandes Momentos en Rock y Roll: Musica Popular Tras las Decadas	Inductee spotlight: Frank Zappa
	Hip-Hop Technology: From Turntables to Computers	Planet Rock: Global Pop and Cultural Exchange	Rock and Roll Reactions: Records, Radio and the Birth of Teenage Culture in 1950s America
Professional Development	On the Road: Backstage Pass	On the Road: Opening ActCost: Free (As Available)

Date and Time: [Please list your top 2 choices]

How did you hear about On the Road?

FACILITY INFORMATION

School Name
Videoconferencing Site Name (if different)
School and/or Videoconferencing Mailing Address

Videoconferencing Room Phone Number:

Number of Students Participating:

FACILITY CONTACT INFORMATION (Please fill in where applicable)

Requesting Teacher

Site/Technology Coord.

Local Bridge/Gateway Contact (if applicable)

Name	Name	Name
Title or Grade/Subject	Title or Grade/Subject	Title or Grade/Subject
Office Phone	Office Phone	Office Phone
Mobile Phone	Mobile Phone	Mobile Phone
Fax Number	Fax Number	Fax Number
Email Address	Email Address	Email Address

VIDEO EQUIPMENT INFORMATION

Videoconferencing System Manufacturer and Model

Connection Speed

<384 KBPS

384 KBPS

512 KBPS

>512 KBPS

IP address/ISDN number/ATM (DID number

BILLING INFORMATION

Name:

Organization:

Phone #:

Payment Method:

Check

Visa

Master Card

AMEX

NOTE: To submit credit card information, please contact John Goehrke at (216) 515-1202

SUBMITTED BY (we will contact this person regarding the program):

Name:

Phone:

Email:

I have read and agree to the terms as noted on the "Policy Information" Page.

Oops! I need to start over.

It's all good.

Rock and Roll Hall of Fame Distance Learning Policy